- Email: [email protected]
TREATMENT OF CARDIAC FAILURE IN INFANCY
664 tuberculosis is diagnosed it should be treated in a sanatorium initially and only at home if conditions are as good, for it will be some months before the patient will be sputum-negative. For although treatment works wonders, is still, to T.B. borrow an heraldic phrase, a bar sinister to the escutcheon, needing prolonged treatment away from school or work and supervision for years. Furthermore, the small boy whose case I have quoted could only have been a casual contact, or may even have been infected by tuberculous-laden dust particles; and this being so, I think it must be true of a considerable proportion of infections also. "
Military Hospital,
"
H. FOSTER.
Colchester.
TREATMENT OF CARDIAC FAILURE IN INFANCY
SIR,-I was interested in Dr. Pincus Catzel’s letter of Sept. 8 referring to the dosage of digoxin and chlorothiazide recommended in my article (Aug. 4), and I should like to reply. My article was concerned only with infants-that is to say, children under the age of one year, and not with older children adults. The older age-groups were not mentioned and one did not recommend a dosage of digoxin or chlorothiazide for them. Most infants, particularly those who present with cardiac failure in the first year of life, are small and their weight rarely exceeds 20-25 lb. I tried to point out the most effective and yet non-toxic dose of digoxin and chlorothiazide in this age-group. If one uses Dr. Catzel’s scheme for calculating the dosage for the lower weights, and compares his figures with those recommended by me, it is obvious that on my standards he would not be giving sufficient digoxin, and one of the points I made was to give larger doses than those usually given. As Dr. Catzel pointed out, practitioners are familiar with the adult dose, and for older children one could use his formula or one of the other formulx often used in calculating the dosage for children. I thought I had made it quite clear that the dosage scheme I recommended was only for infants. I do not think that from my article physicians would prescribe digoxin for adults on the dosage scale recommended for infants, which would be excessive. In my article I tried to inform readers of the dosage found most suitable and efficacious without toxic effects or severe electrolyte disturbances in the age-group which was discussed. Royal Liverpool Children’s Hospital, E. GOLDBLATT. Liverpool. or
SIR,-The method of maintaining infants in an inclined position described by Miss Abbot and others (Sept. 8), using plastic pants and zinc-oxide
plaster, seems an improvethe skin-traction
ment on
technique. May I suggest another method ? The washable canvas seat of the "
walkingpen " apparatus recently reported as a means
of
nursing infants upright! makes a useful 1.
Creery, R. D.
G.
Lancet, July 7, 1962, p. 26.
sling for supporting an infant at any angle of inclination (see figure). The infant is encompassed securely and the chief advantage from the nursing standpoint is the ease with which the child can be removed and replaced without undoing or disconnecting any part of the apparatus. General Hospital, South Shields.
R. D. G. CREERY.
FLUORIDE TOOTHPASTES AND INFECTIOUS DISEASES
SIR,-Fluoride-containing dentifrices and chewing tablets are given to suppress lactic fermentation in the saliva in order to combat dental caries. They differ from fluoridated drinking-water, in which the concentration of fluorine is not sufficient to suppress lactic fermentation in the mouth. Lactic fermentation in the saliva is a physiological process and is part of a physiological defence mechanism in the mouth and throat against infection-not only against local infections, such as Vincent’s stomatitis or alveolar pyorrhoea, but also against general infections caused by microorganisms that enter the body via the mouth or nose. Dold et al.demonstrated that human saliva has anti-infectious
properties,
notably
against
Corynebacterium diphtherice.
Others 2-5 showed that the antibacterial action of saliva is due to metabolic products of the oral streptococci. Bethge et al.’ and Bergerascribed it to hydrogen peroxide formed in the saliva. Berridge and Mattick8 found that lactic streptococci inhibit other species by producing hydrogen perioxide. Dold and Ochsenreither 9 showed that saliva has an antibacterial effect on tubercle bacilli. Boennicke 10 demonstrated that hydrogen peroxide is specially toxic to strains of tubercle bacilli that are resistant to isoniazid. Lammers 11 demonstrated that the bacterial antagonism of the oral streptococci to staphylococci is closely associated with lactic fermentation by these streptococci, which are normal inhabitants of the mouth. Oral streptococci produce not only lactic acid, but also hydrogen peroxide.12 Hydrogen peroxide oxidises lactic acid.13-17 In this reaction further hydrogen peroxide is formed which in turn oxidises more lactic acid, and this goes on as long as there is any lactic acid (or lactate) left. This peculiar relationship between the two metabolic products of the oral streptococci -i.e., lactic acid and hydrogen peroxide-strongly indicates that it forms the basis of the physiological defence mechanism in mouth and throat against infectious diseases found by Dold and others. This view is corroborated by my finding,18 that lactic acid formed in the saliva by fermentation breaks down salivary mucin by acid hydrolysis, thus liberating carbohydrates which can serve as substrate for further fermentation. In this way, continuity of lactic fermentation in the saliva is made possible even in the absence of carbohydrates from food sources. It is further corroborated by my finding (unpublished) that the lactic-acid/hydrogen-peroxide system, as produced by the oral streptococci, breaks down salivary mucin in an oxidative manner. This degradation of the mucin is accompanied by a considerable reduction of viscosity. This suggests that one of the functions of the lacto-peroxide system produced by the oral streptococci is to keep the saliva thin and liquid so as to 1.
Dold, H., Lachele, W.,
Du
Dscheng Hsing. Z. Hyg. InfektKr. 1936,
118, 369.
Holzl, H. ibid. 1941, 123, 500. Knorr, M. Arch. Hyg., Berl. 1941, 126, 59. Hegemann, F. Z. Hyg. InfektKr. 1942, 124, 202. Thompson, R., Shibuya, M. J. Bact. 1946, 51, 671. Bethge, J., Soehring, K., Tschesche, R. Z. Naturf. 1947, 2B, 12. Berger, H. Z. Hyg. InfektKr. 1952, 133, 371. Berridge, N. J., Mattick, A. T. R. Int. Dairy Congr. 1953, 3, 1104. 9. Dold, H., Ochsenreither, F. Z. Hyg. InfektKr. 1940, 132, 51. 10. Boennicke, R. ibid. 1955-56, 142, 339. 11. Lammers, T. Dtsch. Zahn-, Mund- und Kieferhlk. 1953, 18, 378. 12. McLeod, J. W., Gordon, J. Biochem. J. 1922, 16, 499. 13. Baeyer, A., Villiger, V. Ber. dtsch. chem. Ges. 1900, 33, 1569. 14. Engler, C. ibid. p. 1103. 15. Fenton, H. J. H., Jones, H. O. J. chem. Soc. 1900, 77, 69. 16. Dakin, H. D. J. biol. Chem. 1908, 4, 91. 17. Ray, G. B. J. gen. Physiol. 1924, 6, 509. 18. Kraus, A. Z. Stomat. 1935, 33, 1361. 2. 3. 4. 5. 6. 7. 8.
Military Hospital,
"
H. FOSTER.
Colchester.
TREATMENT OF CARDIAC FAILURE IN INFANCY
SIR,-I was interested in Dr. Pincus Catzel’s letter of Sept. 8 referring to the dosage of digoxin and chlorothiazide recommended in my article (Aug. 4), and I should like to reply. My article was concerned only with infants-that is to say, children under the age of one year, and not with older children adults. The older age-groups were not mentioned and one did not recommend a dosage of digoxin or chlorothiazide for them. Most infants, particularly those who present with cardiac failure in the first year of life, are small and their weight rarely exceeds 20-25 lb. I tried to point out the most effective and yet non-toxic dose of digoxin and chlorothiazide in this age-group. If one uses Dr. Catzel’s scheme for calculating the dosage for the lower weights, and compares his figures with those recommended by me, it is obvious that on my standards he would not be giving sufficient digoxin, and one of the points I made was to give larger doses than those usually given. As Dr. Catzel pointed out, practitioners are familiar with the adult dose, and for older children one could use his formula or one of the other formulx often used in calculating the dosage for children. I thought I had made it quite clear that the dosage scheme I recommended was only for infants. I do not think that from my article physicians would prescribe digoxin for adults on the dosage scale recommended for infants, which would be excessive. In my article I tried to inform readers of the dosage found most suitable and efficacious without toxic effects or severe electrolyte disturbances in the age-group which was discussed. Royal Liverpool Children’s Hospital, E. GOLDBLATT. Liverpool. or
SIR,-The method of maintaining infants in an inclined position described by Miss Abbot and others (Sept. 8), using plastic pants and zinc-oxide
plaster, seems an improvethe skin-traction
ment on
technique. May I suggest another method ? The washable canvas seat of the "
walkingpen " apparatus recently reported as a means
of
nursing infants upright! makes a useful 1.
Creery, R. D.
G.
Lancet, July 7, 1962, p. 26.
sling for supporting an infant at any angle of inclination (see figure). The infant is encompassed securely and the chief advantage from the nursing standpoint is the ease with which the child can be removed and replaced without undoing or disconnecting any part of the apparatus. General Hospital, South Shields.
R. D. G. CREERY.
FLUORIDE TOOTHPASTES AND INFECTIOUS DISEASES
SIR,-Fluoride-containing dentifrices and chewing tablets are given to suppress lactic fermentation in the saliva in order to combat dental caries. They differ from fluoridated drinking-water, in which the concentration of fluorine is not sufficient to suppress lactic fermentation in the mouth. Lactic fermentation in the saliva is a physiological process and is part of a physiological defence mechanism in the mouth and throat against infection-not only against local infections, such as Vincent’s stomatitis or alveolar pyorrhoea, but also against general infections caused by microorganisms that enter the body via the mouth or nose. Dold et al.demonstrated that human saliva has anti-infectious
properties,
notably
against
Corynebacterium diphtherice.
Others 2-5 showed that the antibacterial action of saliva is due to metabolic products of the oral streptococci. Bethge et al.’ and Bergerascribed it to hydrogen peroxide formed in the saliva. Berridge and Mattick8 found that lactic streptococci inhibit other species by producing hydrogen perioxide. Dold and Ochsenreither 9 showed that saliva has an antibacterial effect on tubercle bacilli. Boennicke 10 demonstrated that hydrogen peroxide is specially toxic to strains of tubercle bacilli that are resistant to isoniazid. Lammers 11 demonstrated that the bacterial antagonism of the oral streptococci to staphylococci is closely associated with lactic fermentation by these streptococci, which are normal inhabitants of the mouth. Oral streptococci produce not only lactic acid, but also hydrogen peroxide.12 Hydrogen peroxide oxidises lactic acid.13-17 In this reaction further hydrogen peroxide is formed which in turn oxidises more lactic acid, and this goes on as long as there is any lactic acid (or lactate) left. This peculiar relationship between the two metabolic products of the oral streptococci -i.e., lactic acid and hydrogen peroxide-strongly indicates that it forms the basis of the physiological defence mechanism in mouth and throat against infectious diseases found by Dold and others. This view is corroborated by my finding,18 that lactic acid formed in the saliva by fermentation breaks down salivary mucin by acid hydrolysis, thus liberating carbohydrates which can serve as substrate for further fermentation. In this way, continuity of lactic fermentation in the saliva is made possible even in the absence of carbohydrates from food sources. It is further corroborated by my finding (unpublished) that the lactic-acid/hydrogen-peroxide system, as produced by the oral streptococci, breaks down salivary mucin in an oxidative manner. This degradation of the mucin is accompanied by a considerable reduction of viscosity. This suggests that one of the functions of the lacto-peroxide system produced by the oral streptococci is to keep the saliva thin and liquid so as to 1.
Dold, H., Lachele, W.,
Du
Dscheng Hsing. Z. Hyg. InfektKr. 1936,
118, 369.
Holzl, H. ibid. 1941, 123, 500. Knorr, M. Arch. Hyg., Berl. 1941, 126, 59. Hegemann, F. Z. Hyg. InfektKr. 1942, 124, 202. Thompson, R., Shibuya, M. J. Bact. 1946, 51, 671. Bethge, J., Soehring, K., Tschesche, R. Z. Naturf. 1947, 2B, 12. Berger, H. Z. Hyg. InfektKr. 1952, 133, 371. Berridge, N. J., Mattick, A. T. R. Int. Dairy Congr. 1953, 3, 1104. 9. Dold, H., Ochsenreither, F. Z. Hyg. InfektKr. 1940, 132, 51. 10. Boennicke, R. ibid. 1955-56, 142, 339. 11. Lammers, T. Dtsch. Zahn-, Mund- und Kieferhlk. 1953, 18, 378. 12. McLeod, J. W., Gordon, J. Biochem. J. 1922, 16, 499. 13. Baeyer, A., Villiger, V. Ber. dtsch. chem. Ges. 1900, 33, 1569. 14. Engler, C. ibid. p. 1103. 15. Fenton, H. J. H., Jones, H. O. J. chem. Soc. 1900, 77, 69. 16. Dakin, H. D. J. biol. Chem. 1908, 4, 91. 17. Ray, G. B. J. gen. Physiol. 1924, 6, 509. 18. Kraus, A. Z. Stomat. 1935, 33, 1361. 2. 3. 4. 5. 6. 7. 8.